Dysphagia

The table below gives characteristic exam question features for conditions causing
dysphagia. Remember that new-onset dysphagia is a red flag symptom that requires
urgent endoscopy, regardless of age or other symptoms.

Causes Notes
Oesophageal Dysphagia may be associated with weight loss, anorexia or
cancer vomiting during eating
Past history may include Barrett's oesophagus, GORD,
excessive smoking or alcohol use
Oesophagitis There may be a history of heartburn
Odynophagia but no weight loss and systemically well
Oesophageal There may be a history of HIV or other risk factors such as
candidiasis steroid inhaler use
Achalasia Dysphagia of both liquids and solids from the start
Heartburn
Regurgitation of food - may lead to cough, aspiration
pneumonia etc
Pharyngeal More common in older men
pouch Represents a posteromedial herniation between thyropharyngeus
and cricopharyngeus muscles
Usually not seen but if large then a midline lump in the neck
that gurgles on palpation
Typical symptoms are dysphagia, regurgitation, aspiration and
chronic cough. Halitosis may occasionally be seen
Systemic Other features of CREST syndrome may be present, namely
sclerosis Calcinosis, Raynaud's phenomenon, oEsophageal dysmotility,
Sclerodactyly, Telangiectasia

As well as oesophageal dysmotility the lower oesophageal

sphincter (LES) pressure is decreased. This contrasts to
achalasia where the LES pressure is increased
Myasthenia Other symptoms may include extraocular muscle weakness or
gravis ptosis
Dysphagia with liquids as well as solids
Globus There may be a history of anxiety
hystericus Symptoms are often intermittent and relieved by swallowing
Usually painless - the presence of pain should warrant further
investigation for organic causes

Causes of dysphagia - by classification

As with many conditions, it's often useful to think about causes of a symptom in a
structured way:

Classification Examples
Extrinsic  Mediastinal masses
 Cervical spondylosis

Oesophageal wall  Achalasia

 Diffuse oesophageal spasm
 Hypertensive lower oesophageal sphincter

Intrinsic  Tumours
 Strictures
 Oesophageal web
 Schatzki rings

Neurological  CVA
 Parkinson's disease
 Multiple Sclerosis
 Brainstem pathology
 Myasthenia Gravis

Investigation

All patients require an upper GI endoscopy unless there are compelling reasons for
this not to be performed. Motility disorders may be best appreciated by undertaking
fluoroscopic swallowing studies.

A full blood count should be performed.

Ambulatory oesophageal pH and manometry studies will be required to evaluate

conditions such as achalasia and patients with GORD being considered for
fundoplication surgery.